Laryngopharyngeal Reflux

LPR image

What is LPR and LSN?: Laryngopharyngeal Reflux Disease (LPR or airway reflux) develops when stomach acid, bile and pepsin travels up into your throat and beyond. These may irritate the mucus membranes of the upper airways causing microtrauma, inflammation, mucosal thickening,  and sticky dry mucus. This may lead postnasal drip, globus sensation, throat clearing, cough and voice changes. Most also experience “heartburn and acid brash”, "regurgitation" or “indigestion”, but several patients do not have these complaints.  Some of these symptoms may be caused by indirect injury from inflammation reflexes triggered by activation of the vagal nerve in the lower oesophagus.  Laryngeal sensory neuropathy (LSN) which may develop after a virus (postviral vagal neuropathy is an alternative diagnosis), toxin or trauma or unknown cause may, independent of reflux, trigger identical symptoms. Both may exist together and obstructive sleep apnoea may worsen both. With careful treatment, it is usually reversible.

  • sensation of drainage down the back of the throat or excessive mucus
  • feeling of something caught in the throat (sometimes a tickling or burning sensation) or "globus sensation"
  • chronic cough
  • nocturnal asthma
  • post-nasal drip
  • sore throat, throat clearing or tickle
  • hoarseness
  • difficulty swallowing
  • prolonged vocal warm-up (for singers)
  • loss of the high end of the vocal rang
  • ear pressure, belching, and halitosis

DIAGNOSIS OF LPR/LSN: There is no perfect test to diagnose LPR and we need more research. Usually patients are given the diagnosis LPR with compatible symptoms,  objective test evidence of airway reflux and after their voice box or throat is found irritated or swollen and sinister or alternative causes have been excluded. These changes may have been noted by an ENT surgeon using a rigid or flexible telescope called laryngoscopy or nasendoscopy, or by a gastroenterologist during a gastroscopy. However, the diagnosis can often difficult. These throat and voice box changes are commonly seen in healthy "non-refluxers" and as a normal variation. Other non-LPR causes for these symptoms or throat changes are common. Laryngopharyngeal inflammation from overuse or voical strain, dryness, upper respiratory tract infection, habituated behavioral trauma, allergy, and the like is also common and will usually settle with time often without treatment. It is important to carefully exclude many confounding factors associated with laryngopharyngeal complaints (chronic laryngopharyngitis due to tobacco, alcohol, allergy, infections, asthma inhalers, environmental irritants, poor vocal hygiene, muscle tension dysphonia), along with asthma, chronic rhinosinusitis and postnasal drip, angina, psychological distress and more generalised gut motility problems like gastro-oesophageal neuromuscular disorders and slow transit constipation. Some have more than one diagnosis.

Successful response to a treatment trial helps the diagnosis. The treatments aim both to reduce acid and bile refluxing from the stomach into the larynx and also to settle hypersensitive misfiring nerves in your pharynx and larynx and oesophagus. There is no test for LSN or sensory nerve damage. Usually the only clue to LSN is a sudden onset after a viral illness and good relief with neuropathy treatment. Rarely there may be a muscle problem with the uvula or vocal cords not moving properly. Your symptoms along with this swelling and inflammation will eventually resolve with treatment, although it may take a few months.  Other than medication, treatments include voice retraining with a speech therapist, behavourial therapy to break any cough-irritation cycle and laxatives and bowel training if constipated. If treatment has not worked after several months on PPIs, and LPR is still suspected, you may undergo multichannel intraluminal impedance and pH monitoring (MII-pH). This involves placing a small tube (catheter) through your nose and down into your swallowing passage (oesophagus). The catheter is worn for a 24-hour period. The pH probe measures the amount of acid that refluxes into your throat but only the impedance testing may detect nonacid reflux or some aerosolized molecules. This test is often not necessary, may under or over-diagnose LPR (with some false negatives and positives), and much argument and little consensus among experts internationally on its validity, but can provide important information in certain cases. The nuclear medicine reflux study and oral salivary pepsin test (or Peptest®) are sometimes ordered and these share with the MII-pH a lack of consensus from experts on validity with arguments on what is a normal or abnormal test. With some patients, a gastroscopy may be need to examine upper digestive tract for pre-malignant oesophageal changes, hiatus hernia or to consider gastroparesis.

TREATMENT OF LPR/LSN: Most of the time, LPR and LSN is well controlled with lifestyle changes and medications such as proton pump inhibitors (PPI’s) for LPR and neuropathy medications for LSN like amitryptiline, gabapentin and pregabalin and; at times behavioural and speech therapies needed. In the rare event of severe LPR resistant to simple measures, proven on a pH probe study, surgery may be needed, particularly if there are oesophageal symptoms. The surgery is called a Laparoscopic Nissen Fundoplication and it needs careful consideration risks and benefits.

Ten secrets to treating LPR

If postural or night time symptoms predominate are decreasing the evening meal size and fasting for several hours before retiring is important and, if obese, weight loss through appropriate changes to diet and lifestyle. Some have clear food and drink triggers which . There will be some who try everything without benefit: losing 5-10kg, decreasing potential food and drink triggers which irritate the oesophagus or transiently lower the pressure in the lower oesophagus' antireflux valve and avoiding night time meals . However, it is important that you work out what worsens your reflux and some of these changes may work:

1. REDUCE CAFFEINE AND ACIDIC DRINKS, CHOCOLATE AND MINT. This includes coffee, tea, and caffeinated soft drinks. Soft drinks such as Coke and Pepsi are acidic, (pH of 2.3), and the carbonation leads to belching and further reflux of acid into the throat. Other acidic juices (orange, grapefruit, lime, cranberry) and tomato can be irritating for some. Chocolate and mint chemically cause the lower esophageal sphincter to loosen, triggering acid reflux in others

2. REDUCE ALCOHOL, especially in the late evening and before bedtime.

3. QUIT SMOKING, this includes nicotine patches increase reflux in many decreasing the function of the lower oesophageal sphincter valve and delaying the stomach emptying

4. REDUCE FRIED, FATTY or WINDY VEGETABLES  from YOUR DIET. A low-fat diet is a good way to avoid reflux for many. Windy vegetables like the cruciferous group (cabbage, brussel sprouts, broccoli), Onions and garlic are notorious for causing reflux in others.

5. REDUCE highly refined, highly processed, sugary and low fibre foods including junk food. Favour a diet high in complex carbohydrates and whole foods which include the skin of fruits and vegetables, whole grains, seeds, and naturally high fibre foods. If you are seeking more direction consult a dietitian and review the below diet plan. Lechien et al got some good results with this alkaline, protein, low fat diet (see below)

6. LOSE WEIGHT if you’re overweight. Avoid tight-fitting clothing and target 3kg or 5-10% weight loss over 6-12 months rather than an impractical ideal body weight. Bloating and abdominal distention from constipation or windy vegetables may need attentions.

7. STOP EATING 3- 4 HOURS BEFORE GOING TO BED. Eating a heavy high fat meal just before going to sleep is especially bad for your reflux condition. Try having your main meal at lunch and having less for dinner.

8. SLEEP ON YOUR LEFT SIDE and ELEVATE THE HEAD OF YOUR BED 10-15cm by placing wood or bricks under the bedhead or a Styrofoams mattress wedge. If your symptoms are worse in the morning or at night, (indicating active reflux at night), this step is important. Most patients have daytime reflux disease, and this step is not necessary in 2/3 of patients.Placing several pillows under your head does not substitute for raising the head of the bed; in fact, this manoeuvre can make the problem worse.

9. Break the cough/throat clearing-irritation cycle. Avoid throat or voice strain and trauma. Treat any untreated allergy, asthma, postnasal drip. Enlist family and friends in coaching away from the repetitive trauma of coughing or throat clearing. Try to replace your cough or clearing habit with either sipping water or a non-phonated "silent cough or clearance." The “silent cough” is a way to clear the throat without violently banging the vocal folds together.  To do this: breathe in air and blow it out fast through your throat & mouth without making a sound. Immediately tuck your chin down toward your chest & make a strong swallow. The silent cough often clears mucous that clings to the vocal folds or near them, and helps to prevent unnecessary trauma to the vocal folds.  Then, your voice box has a better chance of recovering quicker (see youtube video).  Try decreasing mucus viscosity with old fashioned "lemon drops" or chewing gum. If your work or hobbies include using your voice a lot or exposure to toxic fumes, you will need to look at this. You may need professional speech therapy or work place changes.

10. TAKE THE MEDICINES THE WAY YOUR DOCTOR HAS PRESCRIBED FOR YOU.

  • PPI TWICE A DAY. In most cases, your doctor will prescribe a “proton pump inhibitor” drug (PPI) such as Nexium, Zoton, Pariet, Losec, Somac, pantoprazole, lanzoprazole, omeprazole, esomeprazole, rabeprazole. These drugs may be prescribed initially TWICE A DAY (before breakfast and before dinner), which is double the usual dose for routine reflux disease.
  • Always take your PPI Medications 1/2-1 hour before food:    Acid is release at meal times. So, if you take them with or after food they don’t work, as  “the horse has already bolted!”
  • Gaviscon (double strength)10ml before bed: Gaviscon provides fast, effective and long lasting relief from heartburn and acid indigestion. It can also be used to relieve the symptoms of conditions such as hiatus hernia and reflux oesophagitis (inflamed food pipe). Gaviscon liquid and tablets contain two active ingredients, sodium alginate and potassium bicarbonate. These two ingredients work together to relieve the symptoms of gastro-oesophageal reflux, such as heartburn.